Assessment of the Diagnostic Accuracy and Reliability of the HEART Score Calculated by Ambulance Nurses Versus Emergency Physicians.

Chest pain is a common complaint for consultation of emergency medical services worldwide. Currently, ambulance nurses (AN) base their decision to transport a patient to the hospital on their own professional experience. The HEART score could improve prehospital risk stratification and patient treatment. The aim of this study is to investigate the interrater reliability and predictive accuracy of the HEART score between AN and emergency physicians (EP). A retrospective analysis on data of 569 patients 18 years and older included in two prehospital HEART score studies. The endpoints are interrater reliability (intraclass correlation [ICC]) and predictive accuracy for major adverse cardiac events within 30 days of the HEART score calculated by AN versus EP. Predictive accuracy is sensitivity, specificity, positive predicted value (PPV) and negative predicted value (NPV). Interrater reliability was good for total HEART score (ICC 0.78; 95% CI 0.75-0.81). However, focusing on the decision to transport a patient, the ICC dropped to 0.62 (95% CI 0.62-0.70). History and Risk factors caused the most variability. Predictive accuracy of HEART differed between AN and EP. The HEART score calculated by AN was sensitivity 91%, specificity 38%, PPV 26%, and NPV 95%. The HEART score calculated by EP was sensitivity 98%, specificity 32%, PPV -26%, and NPV 99%. With a cut-off value of 0-2 for a low HEART score, predictive accuracy significantly improved for the HEART score calculated by AN: sensitivity 98%, specificity 18%, PPV 22%, and NPV 98%. Our study shows a moderate interrater reliability and lower predictive accuracy of a HEART score calculated by AN versus EP. AN underestimate the risk of patients with acute chest pain, with the largest discrepancies in the elements History and Risk factors. Reconsidering the cut-off values of the low-risk HEART category, as well as a carefully developed training program, will possibly lead to a higher interrater reliability of the HEART score and higher predictive accuracy used by AN.

Noninvasive assessment and quantification of tumour vascularisation using MRI and CT in a tumour model with modifiable angiogenesis - An animal experimental prospective cohort study.

BACKGROUND: To investigate vascular-related pathophysiological characteristics of two human lung cancers with modifiable vascularisation using MRI and CT. METHODS: Tumour xenografts with modifiable vascularisation were established in 71 rats (approval by the Animal Care Committee was obtained) by subcutaneous transplantation of two human non-small-cell lung cancer (NSCLC) cells (A549, H1299) either alone or co-transplanted with vascular growth promoters. The vascularity of the tumours was assessed noninvasively by MRI diffusion-weighted-imaging (DWI), T2-weighted, and time-of-flight (TOF) sequences) as well as contrast-enhanced CT (CE-CT), using clinical scanners. As a reference standard, histological examinations (CD-31, fluorescent beads) were done after explantation. RESULTS: Microvessel density (MVD) was higher in co-transplanted tumours (171 ± 19 number/mm2) than in non-co-transplanted tumours (111 ± 11 number/mm2; p = 0.002). Co-transplanted tumours showed higher growth rates and larger tumour vessels at TOF-MRI as well as larger necrotic areas at CE-CT. In co-transplanted tumours, DWI revealed higher cellularity (lower minimal ADCdiff 166 ± 15 versus 346 ± 27 mm2/s × 10-6; p < 0.001), highly necrotic areas (higher maximal ADCdiff 1695 ± 65 versus 1320 ± 59 mm2/s × 10-6; p < 0.001), and better-perfused tumour stroma (higher ADCperf 723 ± 36 versus 636 ± 51 mm2/s × 10-6; p = 0.005). Significant correlations were found using qualitative and quantitative parameters: maximal ADCperf and MVD (r = 0.326); maximal ADCdiff and relative necrotic volume on CE-CT (r = 0.551); minimal ADCdiff and MVD (r = -0.395). CONCLUSIONS: Pathophysiological differences related to vascular supply in two human lung cancer cell lines with modifiable vascularity are quantifiable with clinical imaging techniques. Imaging parameters of vascularisation correlated with the results of histology. DWI was able to characterise both the extent of necrosis and the level of perfusion.

Diabetes-Related Burden and Distress is Low in People with Diabetes at Outpatient Tertiary Care Level.

OBJECTIVE: The importance of diabetes-related distress (DRD) for the treatment of diabetes is emphasized in national and international guidelines recommending routinely screening for psychosocial problems. To detect DRD, the PAID (Problem Area In Diabetes) questionnaire provides a valid and reliable instrument. RESEARCH DESIGN AND METHODS: 783 patients with diabetes mellitus type 1 (DM1, n=191, age 54.5 y, diabetes duration 22.5 y, HbA1c 7.2% (55 mmol/mol)) and type 2 (DM2, n=592, age 66.6 y, diabetes duration 15.6 y, HbA1c 7.0% (60.1 mmol/mol)) were interviewed with the PAID and WHO-5 questionnaire in a University outpatient department for endocrinology and metabolic diseases in 2012. A PAID score≥40 (range 0-100) was considered as high DRD. RESULTS: The mean PAID score was 17.1±15.1 in all participants. Only 8.9% of all responders showed high DRD (score≥40). The PAID score neither differed in people with DM1 and DM2, nor between participants with DM2 with or without insulin therapy. Females achieved significantly higher scores than men (19.0±16.6 vs. 15.6±13.7, p=0.003). A strong negative correlation existed between the PAID score and the WHO-5 Well-being Index (r=- 0.482, p<0.001). A 10 points higher WHO-5 Well-being Index was associated with 15.9 points lower PAID score in people with DM1 (p<0.001), and 9.2 points lower PAID score in DM2 (p<0.001), respectively. One percent higher HbA1c was associated with an increase of diabetes-related distress by 2.5 points in people with DM1 and by 2.0 points in people with DM2. CONCLUSIONS: Less than 10% of our outpatients with diabetes showed high diabetes-related distress.

Routine outcome monitoring and process quality in mental health care: a descriptive study in daily practice.

RATIONALE, AIMS AND OBJECTIVES: Routine outcome monitoring (ROM) is used to improve quality of health care by improving the process of care. ROM was introduced nationwide in mental health care in the Netherlands with the primary goal of enhancing the quality of treatment. This study aims to establish the impact of ROM on the process quality of treatment in the daily practice of secondary mental health care in the Netherlands. METHODS: Two cohorts from the same treatment programme were identified, before and after implementation of ROM. Data on patient characteristics, presence of baseline ROM measurement and indicators of the quality of the treatment process were retrieved from the electronic health care information system. Patient data were collected until 6 months after enrolment in the treatment programme. The magnitude of the effect of ROM on the quality of the treatment process was established. RESULTS: The pre-ROM cohort comprised 271 patients and 231 patients constituted the post-ROM cohort. In the ROM cohort, both indicators for process quality 'presence of treatment plan' and 'presence of cancellations' were significantly higher; the odd ratios were 3,37 [confidence interval (CI) 2.32-4.89] and 1,63 (CI 1.14-2.33), respectively. CONCLUSIONS: Indicators on process quality are important for understanding and establishing the impact of ROM in daily practice of secondary mental health care. Implementing ROM moderately increased the presence of a treatment plan. While this suggests improved treatment agreement, it did not result in better compliance of patients with individual treatment activities, as presence of cancellations was significantly higher after introduction of ROM.

Healthcare utilization of people with type 2 diabetes in Germany: an analysis based on health insurance data.

AIMS: This population-based study assesses the healthcare utilization of people with Type 2 diabetes by analysing routine data from Allgemeine Orts-Krankenkasse (AOK), the largest statutory health insurance provider in Germany. METHODS: Anonymized billing data from all AOK-insured persons with at least one day of insurance during the evaluation year 2010 were analysed. Treatment and cost data from all areas of inpatient and outpatient care were available, as was information regarding patient age and sex. International Classification of Diseases (ICD-10) diagnosis and Anatomical Therapeutic Chemical (ATC) classification were used to identify 2.7 million insured persons with diabetes. RESULTS: The age- and sex-standardized prevalence of Type 2 diabetes was 9.8%. Of those patients identified, 33.9% had at least one diabetes-related complication and 83.0% had a diagnosis of hypertension. Almost two-thirds (63.1%) received antihyperglycaemic medication. Metformin and sulfonylurea were prescribed most often; medications without proof of benefit in endpoint studies were prescribed much less frequently. People without diabetes were admitted to hospital only half as often as those with Type 2 diabetes. The projected total expenditure in Germany for all people with Type 2 diabetes amounted to approximately €33.3 billion in 2010. CONCLUSIONS: This study shows an increase in both the prevalence of diabetes and treatment costs. The majority of people with Type 2 diabetes were aged 70 years or older. One third of this group has diabetes-related complications. Antihyperglycaemic medications without proof of benefit in endpoint studies were prescribed much less frequently than drugs with proof of benefit.

Development and validation of an assessment instrument for teaching evidence-based practice to students in allied health care: the Dutch Modified Fresno.

UNLABELLED: To enable students to become competent evidence-based working professionals, teaching evidence-based practice (EBP) to students in allied health care has to be effective. Measuring effectiveness of EBP curricula, however, appears to be difficult due to the lack of valid instruments for this target population. The effort needed to develop and validate a new instrument is easily underestimated. This article details this process applied to an existing EBP measurement tool. AIMS: This study focuses on the development and validation of an instrument measuring the effectiveness of teaching EBP to Dutch students in allied health care. METHODS: The instrument was developed from a translated Fresno Test, using a Delphi panel where face validity was assessed. To determine reliability and construct validity, we used a cross-sectional design with four groups of students (n = 169 total) with different levels of education in EBP. RESULTS: Cronbach's alpha was 0.832, and inter-rater reliability ICC was 0.985 (95% CI 0.976-0.991). The content validity index was 0.92. Mean scores of all four groups were statistically different from each other on a p < 0.05 level. Responsiveness was 3.2 for more extreme groups and 0.9 for more similar groups. CONCLUSION: The Dutch Modified Fresno is a reliable and valid instrument to measure effects of teaching EBP in the domains knowledge and skills in the aforementioned population. The instrument is able to detect minimal important changes over time.

Differences in the quality of diabetes care caused by social inequalities disappear after treatment and education in a tertiary care centre.

AIM: To assess the relationship between social status and quality of diabetes care in a tertiary care centre in Germany. METHODS: Social status was assessed in 940 consecutive patients in a university outpatient department by a questionnaire. The assessment comprised three components: education, highest professional position and household net income (total score 3-21). Quality of diabetes care was measured by HbA(1c) , blood pressure and BMI. The influence of social status on quality measures was analysed at entry and last visit by fitting linear mixed models. RESULTS: At the entry visit, patients with lower social status had a higher HbA(1c) compared with patients with higher status (0.06% per each point of social score difference). After a mean follow- up of 6.0 years (Type 2 diabetes) and 9.4 years (Type 1 diabetes) no significant differences in HbA(1c) could be found. However, difference in BMI (-0.41 kg/m² per each point of social score) persisted at last observation. Blood pressure was only negligibly affected by the care programme. CONCLUSIONS: Low social status is associated with worse quality of diabetes care at entry in a tertiary care centre. The differences in HbA(1c) disappeared after treatment and structured education, whereas the difference in BMI persisted. There was no significant influence of social status or treatment on blood pressure.

Better HbA1c and blood pressure control in patients with diabetes mellitus treated at a primary health care level 10 years after initiation of a diabetes quality improvement program.

OBJECTIVE: Deutsche BKK, a German health insurance company, initiated in 1997 a diabetes quality improvement programme. Changes in HbA (1c) and blood pressure (BP) from 1997 to 2006 are presented. METHODS: Between 1997 to 2006 n=15 096 patients with diagnosed type 1 (6.7%) or type 2 (91.4%) diabetes were recruited by 351 primary care physicians. HbA (1c), BP, serum creatinine, microalbuminuria and presence of diabetic complications (nephropathy, retinopathy, neuropathy) were documented once per year. Physicians received an extra payment of Euro 25 as an incentive for each enrolled and examined participant. RESULTS: Systolic BP decreased by 10.5 ± 0.9 mmHg (baseline 149 ± 21.5), diastolic BP by 4.0 ± 0.46 mmHg (baseline 82.8 ± 10.6), HbA (1c) by 0.55 ± 0.069% (baseline 7.62 ± 1.63) and more patients achieved acceptable HbA (1c) <7% (42.5 vs. 59.9%) and BP <140/90 mmHg (84.9 vs. 94.6%). CONCLUSIONS: HbA (1c) and BP of patients with diabetes mellitus improved while participating in a yearly structured screening programme, performed by primary care physicians in a health insurance initiated quality improvement programme. The intense monitoring derives from extra remuneration of the physicians and the patients' involvement in the quality assurance process. The pre-requisite for remuneration is that the data sheet must be signed by both patient and physician.

A novel balloon angioplasty catheter impregnated with beta-particle emitting radioisotopes for vascular brachytherapy to prevent restenosis; first in vivo results.

BACKGROUND: According to early clinical trials, vascular brachytherapy performed prior to or shortly after angioplasty is very effective in reducing restenosis rates. The purpose of this study was to investigate the effects of a novel radioactive catheter that allows simultaneous balloon angioplasty and beta-particle irradiation in the prevention of restenosis. MATERIAL AND METHODS: The balloon surface of an angioplasty catheter was impregnated with the radioisotope(32)P. Dosimetry calculations using a Monte Carlo method were performed at a radial distance of 0.2 mm from the balloon surface. Rabbit iliac arteries were dilated and simultaneously irradiated with a dose of 20 Gy delivered to the adventitia. Control arteries were only dilated and not irradiated. Neointimal areas, cell numbers and the perimeter of the arteries were measured by histomorphometry after 6 weeks. RESULTS: Neointima formation was reduced after balloon dilatation and simultaneous beta-particle irradiation using the(32)P impregnated angioplasty catheter as compared to balloon dilatation alone with a non-impregnated catheter (0.09+/-0.06 vs 0.27+/-0.09 mm(2)neointimal area and 168+/-45 vs 360+/-133 cells/0.05 mm(2)neointima, P<0.001 vs control, respectively). In addition, balloon dilatation with the(32)P impregnated angioplasty catheter increased the vessel perimeter as compared to balloon dilatation with a non-impregnated catheter (4. 7+/-0.2 vs 3.9+/-0.3 mm, P<0.001 vs control). CONCLUSIONS: Simultaneous balloon dilatation and vascular brachytherapy with a novel(32)P impregnated angioplasty catheter markedly reduces restenosis in vivo by preventing neointimal hyperplasia and constrictive vascular remodelling.

Vision 2000: the transformation of professional practice.

This century has seen miraculous advances in health care. Despite all our progress, however, there are some serious flaws in today's health care systems that demand our attention. This article describes the approach our integrated delivery system has taken to meet this challenge through implementation of the Transformational Model for Professional Practice, and the outcomes we have achieved.

Recognition of malocclusion: an education outcomes assessment.

The purpose of this study was to assess the outcome of predoctoral orthodontic dental education in an American dental school. A test was used that measured the clinical abilities of dental students in the diagnosis of malocclusion in children, as well as their didactic abilities in answering select questions from recent national board examinations in orthodontics. The records of 7 children with different types of malocclusion were selected from the practice of a board-certified orthodontist. These cases were presented to dental students who were asked to make diagnoses and recommendations for treatment. The results of the didactic and clinical tests were used to assess the outcome of the predoctoral dental curriculum in imparting orthodontic knowledge to future general dentists. Didactic knowledge increased over the 4 years of dental education. First year students answered 30% of the questions correctly, whereas fourth year students answered 59% correctly. The relationship between clinical diagnostic skills and dental education, however, was not as strong. The fourth year students answered 70% of questions concerning the 7 cases correctly. These results indicate that fourth year dental students demonstrated only slight improvement compared with first year students, who answered 65% of the questions correctly. Thus, this study indicated that orthodontic diagnostic skills, as measured by the clinical test used, did not improve substantially during 4 years of undergraduate dental education.

Health impact of head and neck cancer.

A multidimensional Head and Neck Quality of Life (HNQOL) instrument and a general health status measure were administered to 397 patients with head and neck cancer. Scores for the 4 domains of the HNQOL (communication, eating, pain, and emotional well-being) were calculated. Patient demographics, comorbidities, clinical characteristics, treatment data, disability status, and a global "overall bother" score were assessed. When compared with the US population aged 55 to 64 years, the group had significantly worse scores in the 8 health domains of the SF-36. Patients' overall bother scores from the head and neck cancer treatment correlated best with the HNQOL emotion domain (r = 0.71) and the HNQOL pain domain (r = 0.63), and least with the patients' perception of their response to treatment (r = 0.39). Pain, eating, emotion, physical component summary score, age, and an interaction term between eating and emotion were significant predictors for overall bother. Of the 217 patients who were working before the diagnosis of cancer, 74 (34. 1%) reported that they had become disabled. Patients who had more than 1 type of treatment were 5.9 times more likely to report themselves as disabled (odds ratio [OR] = 5.94, P < 0.01), even after adjusting for age, emotion score, and physical component summary score, which were other factors that predicted disability.

[Results of stereotactic guidance of breast excisional biopsy versus stereotactic core biopsy in occult breast lesions]. / Ergebnisse der stereotaktisch gezielten Mamma-PE versus stereotaktisch gezielter Corebiopsie bei okkulten Mammaveränderungen.

Interventional procedures, whether markings or core biopsies, are very important for clarifying non-palpable breast lesions. Both at present as well as in future--in the age of breast screening--such methods must be used more and more. Although breast screening is not carried out on an organized basis in our country, it is gaining importance. Currently there is a covert screening in progress and women are availing this facility to an increasing extent. Various organisations including the press and audio-visual media have arisen the interest of the population. An increase in diagnostic studies is being flanked by an increase in surgical activity. As a result, on the one hand a larger number of small carcinomas as well as benign lesions are being operated. This has brought the cost-bearers, i.e. all of us, to the limits of what can be done. Surgery costs money. One solution to the problem is preoperative marking which is used in all patients suspected of carcinoma, and the other is core biopsy which is used in lesions that appear benign on X-rays. Radiologically benign lesions are not histological diagnoses. Although a well trained radiologist will make the correct diagnosis in 95 to 98% of cases, the possibility of error is still 2 to 50%. In the light of this knowledge, it would appear logical to operate all apparently benign lesions. However, a more intensive use of bioptic procedures is a solution to this problem. To compare costs: Surgery for clarification of a lesion involves a hospital stay of about 3 days while bioptic studies can be carried out on an outpatient basis. Besides, surgery costs 2 to 3 times more than bioptic studies, depending on the hospital and the bioptic material used. A core biopsy needle costs about two-thirds the price of a rotating cannula. However, it should be emphasized that core biopsy is not a method of treatment and will never be one. It should remain a diagnostic procedure, although small lesions may well be aspirated by this method. The ABBI systems is intended to be a therapeutic method. At present, no final statement can be made about the utility of this procedure.

Assessment of cerebral perfusion and arterial anatomy in hyperacute stroke with three-dimensional functional CT: early clinical results.

PURPOSE: Our purpose was to determine the clinical feasibility of quantitative three-dimensional functional CT in patients with hyperacute stroke. METHODS: Twenty-two patients who underwent clinically indicated CT angiography were studied: nine patients had no stroke, eight had mature stroke, and five had hyperacute stroke (less than 3 hours since ictus). Maps were obtained of perfused cerebral blood volume (PBV), and CT angiograms were generated by using standard techniques. RESULTS: Normal PBV values (mean +/- SEM) were 4.6 +/- 0.15% in the gray matter, 1.75 +/- 0.09% in the white matter, 2.91 +/- 0.20% in the cerebellum, 3.18 +/- 0.10% in the caudate, 2.84 +/- 0.23% in the putamen, 2.92 +/- 0.29% in the thalamus, and 1.66 +/- 0.03% in the brain stem. For patients with mature stroke, ischemic changes were visible on noncontrast, contrast-enhanced, and PBV scans. In patients with hyperacute stroke, ischemic changes were either absent or subtle before contrast administration, but became apparent on contrast-enhanced scans. Quantitative PBV maps confirmed reduced regional perfusion. CT angiograms in the hyperacute group showed occlusion of vessels in locations appropriate to the PBV deficits seen. CONCLUSION: Quantitative three-dimensional functional CT is feasible for patients with hyperacute stroke. It is performed by using helical CT techniques, and yields measures of cerebrovascular physiological function, which are useful in this patient population.

Clinical outcome of continuous facial nerve monitoring during primary parotidectomy.

OBJECTIVES: To assess whether continuous facial nerve monitoring during parotidectomy is associated with a lower incidence of facial nerve paresis or paralysis compared with parotidectomy without monitoring and to assess the cost of such monitoring. DESIGN: A retrospective analysis of outcomes for patients who underwent parotidectomy with or without continuous facial nerve monitoring. SETTING: University medical center. PATIENTS: Fifty-six patients undergoing parotidectomy in whom continuous electromyographic monitoring was used and 61 patients in whom it was not used. MAIN OUTCOME MEASURES: (1) The incidence of early and persistent facial nerve paresis or paralysis and (2) the cost associated with facial nerve monitoring. RESULTS: Early, unintentional facial weakness was significantly lower in the group monitored by electromyograpy (43.6%) than in the unmonitored group (62.3%) (P=.04). In the subgroup of patients without comorbid conditions or surgeries, early weakness in the monitored group (33.3%) remained statistically lower than the rate of early weakness in the unmonitored group (57.5%) (P=.03). There was no statistical difference in the final facial nerve function or incidence of permanent nerve injury between the groups or subgroups. After multivariate analysis, nonmonitored status (odds ratio [OR], 3.22), advancing age (OR, 1.47 per 10 years), and longer operative times (OR, 1.3 per hour) were the only significant independent predictive variables significantly associated with early postoperative facial weakness. The incremental cost of facial nerve monitoring was $379. CONCLUSIONS: The results suggest that continuous electromyographic monitoring of facial muscle during primary parotidectomy reduces the incidence of short-term postoperative facial paresis. Advantages and disadvantages of this technique need to be considered together with the additional costs in deciding whether routine use of continuous monitoring is a useful, cost-effective adjunct to parotid surgery.

Functional CT with an experimental intravascular contrast agent in the assessment of liver vascular physiology.

RATIONALE AND OBJECTIVES: We evaluated liver vascular physiology with a functional spiral computed tomography (CT) technique and an intravascular contrast agent. METHODS: Eleven rabbits were studied by means of continuous 40-second single-section data acquisition after bolus injection of an experimental contrast agent. Sequential images were reconstructed at 200-msec intervals. Aortic, portal and hepatic venous, and liver time-HU curves were obtained. From these, hepatic blood volume and flow, tissue transit times, and arterial and portal contributions to total liver blood supply were assessed. RESULTS: The following measures were obtained: hepatic blood volume fraction, 0.33 +/- 0.03 (mean +/- standard error); total flow, 241.1 mL/min +/- 33.6 per 100 g of tissue (arterial component, 11.3 mL/min +/- 3.0 per 100 g of tissue; portal component, 226.4 mL/min +/- 30.7 per 100 g of tissue); arterial transit time, 8.7 seconds +/- 1.6; portal transit time, 8.7 seconds +/- 1.3; arterial to portal perfusion ratio, 0.06 +/- 0.01; and calculated arterial and portal perfusion indexes, 0.05 +/- 0.01 and 0.95 +/- 0.01, respectively. CONCLUSION: Functional CT is a promising, high-resolution tomographic imaging technique for evaluating liver perfusion.

Funding nursing education: the Medicare dilemma. Interview by Cheryl Slagle King.

Comprehensive analysis of current Medicare funding for hospital-based diploma programs is multi-factorial, and must incorporate a market of constrained costs, impending Medicare Reform and emerging opportunities for APNs. In addition, consideration must be given to fundamental issues surrounding all aspects of nursing education. APNQ interviews Dr. Carol A. Anderson and Dr. Gail Wolf who make thought-provoking points in arguments covering a spectrum of nursing issues.

Basic principles of MR contrast agents.

Although familiar for CNS enhancement, contrast agents for body MR applications are both similar and different. This short summary emphasizes the basics of tissue relaxation and the added influences of paramagnetic or superparamagnetic pharmaceuticals. An overview of safety and cost considerations is included.